Action Points

Small lesions appear on brain imaging more often in patients who get migraines but they don't appear to have an impact on cognition or stroke risk.

Note that there was no association of migraine with progression of any MRI-measured brain lesions in men.

Small lesions appear on brain imaging more often in patients who get migraines, but they don't appear to have an impact on cognition or stroke risk, researchers found.

Women with migraine were 2.1 times more likely to have progression of deep white matter hyperintensity on MRI over 9 years than controls (P=0.04), almost entirely from new lesions, according to Mark C. Kruit, MD, PhD, of Leiden University Medical Center in Leiden, the Netherlands, and colleagues.

But the higher number of lesions didn't predict worse cognitive performance or faster decline, nor was there an interaction with migraine, the group reported in the Nov. 14 issue of the Journal of the American Medical Association.

Migraine didn't correlate with any brain lesion measures in men in the CAMERA-2 (Cerebral Abnormalities in Migraine, an Epidemiological Risk Analysis 2) study.

That's good news for migraineurs, Robert G. Kaniecki, MD, a neurologist and migraine specialist at the University of Pittsburgh, told MedPage Today in an interview.

"For years, patients have been asking about these lesions, what do they represent? Many have looked at the idea that these are small strokes," he explained.

"As professionals, it gives us information to at least reassure folks that these are not strokes, these are not multiple sclerosis plaques," he added. "They're like freckling of the brain. They're signs of minor brain damage that you can see but they're clinically meaningless."

These kind of lesions seen on MRI have been linked with atherosclerotic disease risk factors, increased risk of ischemic stroke, and cognitive decline in prior studies.

However, "most prior studies were conducted in older participants with larger deep white matter intensity volumes; this cohort is rather young with relatively little volume," the researchers explained.

In an accompanying editorial, Deborah I. Friedman, MD, MPH, of the University of Texas Southwestern Medical Center in Dallas, and David W. Dodick, MD, of the Mayo Clinic in Scottsdale, Ariz., agreed that the findings should be reassuring for patients and physicians, calling the lesion burden seen in the women with migraine "quite small and most likely clinically insignificant."

Still, migraine has been linked to acquired and genetic vasculopathies that contribute to stroke and other neurologic risks, they noted.

"Addressing modifiable risk factors for stroke -- such as obesity, smoking, hypertension, hypercholesterolemia, and physical inactivity -- and avoiding high-dose combined oral contraceptives in women older than 35 years and in those with untreated or poorly controlled vascular risk factors seems prudent," Friedman and Dodick wrote.

The CAMERA 2 trial included 203 of the 295 migraineurs and 83 of the 140 age- and sex-matched controls who had a baseline MRI brain scan in the original CAMERA study, a prospective population-based observational study in the Netherlands, and repeat scans 9 years later.

After additional adjustment for hypertension, diabetes, and education, progression of deep white matter hyperintensity was more common in women with migraine, at 77% compared with 60% of control women (P=0.04).

This progression was almost entirely accounted for by new lesions rather than a expansion of existing lesions.

Surprisingly, progression of these deep white matter lesions was most common in migraine without aura, at 83%.

The infarct-like lesions were associated with a poorer cardiovascular risk profile, with a higher prevalence of clinically-diagnosed stroke, hypertension, and older age.

Notably, cognitive scores were no poorer for migraineurs at follow-up (adjusted P=0.90) or for those with a high load of deep white matter hyperintensity (z score −3.7 with migraine versus 1.4 for controls, adjusted P=0.07).

Cognitive decline wasn't more rapid with a high burden of those lesions, either (P=0.7).

The researchers cautioned about wide confidence intervals and lack of MRI follow-up for about one-third of the original population.

Also, they noted, the cohort was getting older over time, which may have complicated detection of migraine attack-related associations. Migraine attacks usually diminish with age, while other conditions that can cause white matter hyperintensities rise.

Another concern was that the high prevalence of smoking in the cohort (70%) may impact generalizability, Kaniecki pointed out.

Few patients with migraine in the cohort used preventive medication (less than 5%) or triptans and ergots (less than 15%), which precluded analysis.

The study was supported by grants from the National Institutes of Health, the Netherlands Heart Foundation, the Netherlands Organisation for Scientific Research, and the Intramural Research Program at the National Institute on Aging.

Kruit reported having no conflicts of interest to disclose.

Friedman and Dodick reported having no conflicts of interest to disclose.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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